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Madam Wang Xiaopu is an investor from China. Convinced that Singapore’s medical aesthetics industry is a gold mine, she signed a contract to buy over 20,000 shares in a company holding a chain of aesthetic clinics for $32.5 million. She was informed by Dr Goh, a major shareholder in the company, that the clinics have a pre-tax profit of $10 million in 2012, and its pre-tax profit was also growing at a rate of more than 30 per cent a year. The chain, which originally had 14 branches, is now facing insolvency, rendering Madam Wang’s shares worthless.

Madam Wang is just one of many faceless (clueless) foreign investors wooed into the seemingly lucrative local healthcare industry. With millions injected into their war chests, the aggressive clinic management teams spawn dozens of branches, quickly saturating the small local market and creating the illusion of insufficient manpower. I’ve already written about the apparent shortage of dentists which is not due to dentists unable to meet the demand of patients but rather them not meeting the demand from the sheer number of “shell” clinics built. And the drying wells are seen everywhere. Small clinics which used to be doing very well have deregistered themselves from GST. Some have seen a 30-50% drop in revenue. On the ground, clinicians bonded to “high performance” practices are struggling to hit targets and this sometimes results in overwork, over-treatment or even cases of fraudulent claims of which we have seen and will see a lot in the coming months and years.

It is unfortunate that most of those in the know hesitate to comment on this issue before the profession/industry reached this state. They are reticent for a variety of reasons. Some keep quiet because they are in the game themselves. Some are afraid of saying the “wrong” thing. Some simply just don’t want to get “marked”. Why speak out when they are still earning a comfortable income? A doctor who commented on my Facebook posting on this subject quickly changed his mind and removed his comments. That’s how fearful Singaporeans are, even when they need to sound the alarm for a house on fire. Instead of voicing out their concerns, some quietly crawl through loopholes to sustain their income. But for how long can all this last without blowing up in our faces?

As Singapore opens its doors to high net worth new citizens, it’s worthwhile to keep an eye on the industries they invest in. What is the demand for high value medical services which are readily available for a lower price tag and with fewer restrictions/regulations in the region? When profits and ROIs fall far short of investor expectations, the scene will turn really ugly.

Recently, the governing body for dentists in Singapore sent out a circular reminding dental practitioners that they are not allowed to carry out any activity relating to the harvesting of dental pulp tissues and DPSCs (dental pulp stem cells).

The reason behind this prohibition is that “dental pulp tissue and dental pulp stem cells currently (bolding mine) lack clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions.”

Before I go further, I must declare that I have absolutely no interest whatsoever in harvesting dental pulp tissue and neither do I encourage patients to spend money paying for a service which is unlikely to be put to good use in the near future. Sounds a bit like insurance? Well, that’s almost exactly what it is. So if there is currently no evidence that you’re having cancer or kidney failure, why buy a crisis cover? The majority of people who buy insurance will not gain from it, but they buy a policy in case of untoward circumstances because having no evidence of cancer of kidney failure currently does not mean that you won’t get any evidence of cancer or kidney failure in future.

Now let’s take a look at dental stem cells. What are they?

Wikipedia:

Dental pulp stem cells (DPSCs) are stem cells present in the dental pulp, the soft living tissue within teeth. They are multipotent, so they have the potential to differentiate into a variety of cell types. Other sources of dental stem cells are the dental follicle and the developed periodontal ligament.

Why are stem cells such cool stuff? They are like promising recruits in the army. When a battalion of commandos gets wiped out, you can train them to replace the commandos. When an artillery battery gets wiped out, you can train them to be artillery men. These cells give hope for patients who need organ transplants because theoretically (and sometimes in the laboratory), stem cells can be cultivated to produce various kinds of living tissues. However, not all stem cells have the same potential.

When we talk about stem cell potency, there are several levels to consider. A unipotent stem cell refers to a cell that can differentiate along only one lineage. Of all the stem cells, a unipotent stem cell has the lowest differentiation potential. This means that the cell has the capacity to differentiate into only one type of cell or tissue. Unipotent cells are found in the skin. You can technically grow new skin using these stem cells. However, patients who need skin grafts often need them urgently and there is currently no technique that yields quick and consistent results.

Stem cells can also be pluripotent. As far as embryonic origins go, there are only 3 categories of tissues in our body. Depending on its origin, a pluripotent stem cell can differentiate into one of 3 tissue categories. An ectodermal stem cell can grow into ectodermal tissue (skin, nerves). An endodermal stem cell can grow into endodermal tissue (lung, gut lining) and a mesodermal stem cell can grow into mesodermal tissue (muscle, bone, blood, urogenital).

Dental stem cells are multipotent and there is already quite a bit of literature on it. Multipotency describes progenitor cells which have the gene activation potential to differentiate into discrete cell types. They can theoretically be induced to grow into different types of cells (independent of embryonic origin) as in blood, brain and bone. Multipotent cells have been found in cord blood, adipose (fat) tissue, cardiac (heart) cells, bone marrow, and the mesenchymal stem cells (MSCs) which are found in our wisdom teeth. Seeing the huge potential of an insurance concept, businesses have pounced on the opportunity to sell pricey storage facilities for cord blood and even extracted wisdom teeth as they are the most readily available sources of multipotent stem cells.

Right there at the top of cell potency, totipotency represents the cell with the greatest differentiation potential, being able to differentiate into any type of tissue. Totipotent stem cells are only found in an embryo that is a few hours old – before it grows 3 layers. You can theoretically grow an entire organism or organ with a totipotent stem cell, but obviously, you would need to sacrifice a living organism in the process. Ethical issues get in the way, but it gets more interesting.

Induced pluripotent stem cells, commonly abbreviated as iPS cells or iPSCs, are a type of pluripotent stem cell artificially derived from a non-pluripotent cell, typically an adult somatic cell, by inducing a “forced” expression of certain genes and transcription factors. By 2007 scientists have successfully produced human iPSCs derived from human dermal fibroblasts which are not even stem cells. The feat earned Shinya Yamanaka and John Gurdon the Nobel Prize in Physiology or Medicine 2012. This discovery raised a question. Why do we need to store or harvest stem cells at all if they could be made from an ordinary cell?

But let’s not get carried away and drift into the realm of science fiction. Stem cell technology is still in its infancy and the American FDA does not approve any of the stem cell therapies out there. Some are even considered dangerous. Nevertheless, clinics there are already using stem cells to treat problems ranging from arthritis and torn tendons to paralysis and stroke. These patients are willing to take the risk even though researchers say that there’s (currently) no evidence that the treatments work or are even safe.

What do we do to such experimental therapies? We certainly should not encourage them, but the practically harmless process of harvesting cord blood or dental stem cells should both count only as insurance policies. In the case of cord blood, there is only one chance at birth. For teeth, there are more opportunities, though the process is a little more invasive. What will the outcome be? Will we be able to grow new livers and kidneys from teeth? Will induced pluripotency render cord blood and dental tissue banking obsolete? Or will all this research finally lead us to a dead end?

Hundreds of healthy teeth are extracted in Singapore every day to make way for tooth movements and alignment. What’s wrong with banking these teeth? Those who opt for the service are merely placing their bets on the future. Why should they be dictated by the “lack of clinical evidence for therapeutic use and have not been accepted as a form of evidence based therapy for regenerative medicine nor dentistry by the local medical and dental professions”? Pessimistic and cynical as I am, I believe that the final outcome of a dead end to all this research is most unlikely.

Transport Minister Khaw Boon Wan said in Parliament on Mar 7 2018 that while Singapore’s transport fares are currently “affordable”, the Government also needs to ensure the “sustainability” of the transport network.

“We must be careful that (fares) are not priced too cheaply, as maintaining a “high-quality” transport system requires resources,” he said. “Cheap fares are popular, but they are not sustainable.”

The current formula is “inadequate”, he said, and the Public Transport Council (PTC) is reviewing it to take into account “total costs”.

“I am confident that they can work out a fair and sustainable arrangement. Please support the PTC when they make their recommendations,” Mr Khaw said.

And not too surprisingly, the PTC had this to say:

“A widening gap between cost and fares is not sustainable for any public transport network.”

While PTC said it was too early to commit on whether this new component would mean a fare hike at the next review in the third quarter of this year, it pointed to the need to keep the system sustainable.

An interesting coincidence perhaps, but what does the PTC actually do or claim to do? Let’s take a closer look at info extracted from their website.

As the Public Transport Council (PTC), we regulate public transport fares and ticket payment services. We also advise the Minister for Transport on public transport matters. Established in 1987 under the Public Transport Council Act (Cap 259B), we operate within the ambit of the Public Transport Council Act and in accordance with overarching public transport policies.

We strive to bring about a quality and affordable public transport system for the people of Singapore. We also work closely with the public transport industry players and public agencies like the Land Transport Authority (LTA).

Key Function and Objectives

Our key statutory powers include:

Regulating bus and train fares (taxi fare has been deregulated since 1 September 1998);
Promoting and facilitating the integration of bus and train fares for efficient public passenger transport services and facilities;
Regulating ticket payment services for buses and trains;
Regulating penalty fees to deter fare evasion;
Gathering public feedback on any matter relating to bus, train and taxi services in Singapore, through surveys and other methods; and
Advising the Minister for Transport on public transport matters.

PTC’s Council Members are appointed on the basis of their competency, good public standing and wealth of experience, especially their ability to contribute effectively to PTC’s deliberation on public transport issues. The Council Members are chosen from a wide spectrum of society including:

The composition of the Council is made up of a broad and diverse representation from society, which includes academia, labour union, industry and the people sector. This facilitates a wide representation of views from the public. The Council currently comprises 17 members and many of them are regular users of public transport.

So Council members in the PTC are chosen for their competence, good public standing and “wealth of experience”. If you’re talking about “competence” and “good public standing”, then that should rule out an undistinguished guy like me. But I’m not sure what kind of experience they’re looking for. You see, I have taken the MRT on its test run in 1987 and I’ve been taking it almost on a daily basis ever since, enjoying the speed and comfort, showing it off to friends from overseas till the early 2000s. Then, things changed. The passenger load grew at a frightening rate. There was crowding on the platforms, squeezing in the trains. Our once proud and efficient MRT was no longer as reliable and comfortable as it used to be. Then came the frequent breakdowns, delays, death on the rails, tunnel flooding incident and train collision. Does that count as “experience”? More importantly, do the chosen council members have the experiences of watching our MRT deteriorate to its current state? How justified is an increase in fares?

Then on 18th May 2018, Mr Khaw said something even more outrageous and mind-boggling.

“The Public Transport Council (PTC) had mulled over including rail reliability into the formula for calculating public transport fares, but ultimately decided against it. This was partly because reducing fares in the face of an unreliable rail system would mean withdrawing resources from the operators when they, in fact, need to inject more funds to fix the system. When a system is very unreliable, in fact, that is the time to pump in more resources. And because of that, you punish them through reduced fares; you are withdrawing resources from the operators and you’ll be doing exactly the opposite, the wrong thing.”

Yao mo gao chor ah? Since this is newagedentists.com and I’m promoting my book, Dental Phobia, I should come up with an appropriate analogy.

Once upon a time, there was a dentist by the name of Dr Poh Chwee Kee. He had just taken over a thriving dental practice from a retiring senior. He was glad that there was still a lot of materials left behind, so without bothering to order new materials, he used what was available. Then, his patients started coming back to him, complaining of fillings that fell out. Dr Poh Chwee Kee checked his instruments and his filling materials and discovered that the filling materials handed over to him had all been contaminated. He called the supplier and fresh stocks of filling materials would cost him a bomb.

So Dr Poh Chwee Kee informed the patients affected by the contaminated filling material that he would replace their fillings for a higher fee than they had paid for the old fillings that had failed. He explained that maintaining a “high-quality” dental practice requires resources. His profit had fallen 68%.

“Just pay me more lor. Cheap fees and free re-treatment for failed cases are popular, but they are not sustainable.”

Is it his patients’ fault that this problem had occurred? Why should they be made to pay to fix a problem that ought not be there in the first place? Not surprisingly, Dr Poh lost all his patients in no time. Why? Because it’s the service provider’s responsibility to provide a reasonable standard of service. If he fails to do so, he must rectify the problem at his own expense. How can he ask people to pay him more to fix the problem after he has failed to deliver?

The logic is the same, but the situation is very different. Dr Poh did not have the backing of a council that happens to agree with him most if not all the time. He also did not have a monopoly of dental services in his town. For those who do, karma may strike in an unexpected place.

My friend – let’s call him C, had a problem. Actually it’s not really his problem, but his teenage daughter got pregnant – which kind of made it his predicament since he is a highly respected person with a solid reputation in his community. C’s daughter ended up flying off to a European country for an abortion cum holiday before returning to Singapore to attend school. The reason C took the trouble to do that had something to do with this piece of news.

The finer details are still being finalised, but the new Healthcare Services Bill is intended to better “safeguard the safety and well-being of patients” in the changing healthcare environment while enabling the development of new and innovative services that benefit patients. It is also supposed to strengthen governance and regulatory clarity for better continuity of care to patients. It is further assumed that HCS Bill – and the National Electronic Health Record (NEHR) that it mandates – address wider issues of “patient welfare”.

The obvious advantage of this system is that inaccurate or incomplete medical history will be a thing of the past. An unconscious patient brought into A&E will have all his drug allergies and current medical condition clearly displayed for the convenience of the attending physician – assuming he is correctly identified. The core data accessible to future attending physicians include 1) Patient Profile; 2) Events; 3) Diagnosis; 4) Operating Theatre Notes/Procedures/Treatments; 5) Discharge Summary; 6) Medications; 7) Laboratory Reports; 8) Radiology Reports; 9) Immunisation; and 10) Allergies.

The scheme will be implemented in 3 phases. By December 2020, all private medical and dental clinics must comply. Below are some answers to FAQ provided by MOH.

1. Who will be able to access my health records?

Only doctors who are caring for you will be able to access your records.

2. What kind of health information will be captured in the NEHR?

It will include your diagnosis, medications, allergies, and vaccination records. In addition, the system will capture operating theatre notes and procedures, as well as laboratory and radiology reports. It will not, however, include doctors’ personal case notes of each consultation. Yes, every liposuction and fat transfer to the butt that you had will be made known to the doctor giving you a flu shot in the arm.

3. Can my insurance company or employer look up my records through the company doctors?

If anyone wants to look up your records for purposes other than caring for your health, they will have to get explicit consent from you.

4. What if I don’t want anybody to look up my health records?

You can opt out of the NEHR. When you do so, your medical records will still be uploaded into the system, although doctors or other healthcare professionals will not be able to access them. The authorities have said that this will not change for now, although they are open to feedback on the issue.

5. Will all my old health records be uploaded into the NEHR system?

No, there will be no backdating of old health records. And of course, for some procedures, you don’t need to see the medical records to know that they have been performed.

6. What cybersecurity measures will be taken to make sure that all this sensitive information will be protected?

The authorities have said they will take measures similar to what the Inland Revenue Authority of Singapore uses to protect its tax database from hackers and other cybersecurity threats.

My friend C has many friends and colleagues who are doctors. We may assume that every one of them is professional in his/her approach, but we also happen to be one of the most judgemental societies in the world. Will C’s friends and colleagues not look at C’s daughter differently if they know that she had an abortion in her teens? Just look at the way we dis-incentivise single parenthood. I would think that “Victorian” is already a very kind word to use for the total lack of graciousness, compassion and flexibility in granting a faultless child his citizenship.

I seriously think that we need to fix such social stigmas and narrow-mindedness before we even think of implementing something as progressive as the NEHR. But given all the “safeguards” mentioned, does C have any reason to worry that the record of his teenage daughter’s abortion is going to follow her for life, visible to every future doctor that she sees? Maybe not, but would you take the risk if you were in C’s shoes? Wouldn’t it be safer to be totally off the record here? What all this point to, besides better continuity of care to patients as purported, is a boost to outbound medical tourism for procedures ranging from abortion to plastic surgery or treatment for psychiatric conditions and sexually transmitted diseases. The Bill works perfectly for a bunch of hogs, but fails miserably to take human weaknesses and social stigmas into consideration.

There is another issue. The elephant in the room, is that doctors will have to spend a good amount of money just plugging into the NEHR. Clinics whose patients don’t mind the tattered cushions in the waiting area and mouldy walls in the toilet must now fork out money for a business broadband account. It’s no longer optional.

Entering data also takes up time. All this will add to the administrative workload of doctors who are supposed to be clinicians. 30-year-old clinics which have not gone digital estimate that they need to fork out almost $17,000 for software/hardware and put in many hours of familiarisation trials to get started. All this will inevitably translate into higher medical costs. Another boost for outbound medical tourism.

Meanwhile, the policymakers who sit in trendy offices and hold trendy meetings (courtesy of our compliant taxpayers) go about their daily chore of generating more and more work for people whose response can only fall between voluntary acceptance or involuntary compliance.

Dentists have a very simple reason for advising their patients not to consume alcohol after an extraction. Alcohol causes vasodilatation and this may prolong bleeding. There are very few experienced dentists who haven’t had patients showing up at their clinics one day after extraction with a blood-stained pillow (sometimes only the pillow case), livid with fear (not with the loss of blood).

Even in such situations, blood loss is usually quite minimal. Actually, we should be more worried if blood does not reach the wound. Healing gets delayed and a condition called dry socket may occur. It is very painful and takes a while to recover; definitely not something you would rather have over slightly prolonged bleeding.

2017 has not been a good year for me. Business is down and it’s not just in one clinic or two, but practically every dentist I have talked to has complained about a fall in income this year. And it’s the same with my friends who are in the retail and construction business.

Usually, such “perceptions” are not taken seriously. Where are the numbers, the data obtained through surveys or the tracking of “loyalty points”? Not backed by big data and/or a string of abbreviations behind our names, our ideas can only be labelled as perceptions or opinions. Meanwhile, official media sing a very different tune.

Very few dentists who have to deal with the realities on the ground can agree with that headline. Shortage of dentists? They’ve got to be kidding, right? But they’re not. Predictably, this article and many others like it talks about aging population. It seems like common sense that an aging population would lead to a demand for more dentists. Well, yes and no. I’ll come to that in a moment.

Some years ago, I attended a lecture where the speaker showed graphs with dentist to population ratios as evidence that we in Singapore don’t have enough dentists. But the professor failed to mention that in some of those countries with a “healthy” dentist to population ratio, it could be a two-hour drive between two dentists and some practitioners even operate from the backyard of their homes.

In Singapore, how many dentists are there between two MRT stations? How many are there in one neighbourhood shopping mall or town centre? Dozens if not scores of them! There are two adjoining HDB blocks in Toa Payoh where there are three dental clinics and only two medical clinics. The uninitiated may think that folks in that estate must so dentally paranoid that they see the dentist a few times every month just to make sure that their fillings are still in place and their gingivitis scores are good. In reality, the clinics are barely able to make ends meet.

Make no mistake, it’s extremely challenging and competitive out there. So why is there a mismatch between what the big data tells the policy makers and the realty on the ground? The answer is hidden between the lines. The article above goes on to say that “In Singapore, this situation (shortage of dentists) is presently a lived reality in the dental profession. Here, foreign-trained dentists already made up the majority of new dentists registered in recent years.”

Is that even a fair indication that we don’t have enough dentists? The need for a majority of foreign dentists implies that there has been an exponential increase in demand for dental services and our local dentists can’t cope? You guessed it, it’s something else.

With the successful public listing of a chain of dental practices in Singapore, almost half a dozen wannabes have emerged in recent years. As you may have guessed again, most of these IPO hopefuls are backed by foreign investors. For a successful IPO, these dental practices need to demonstrate growth. The result? Dental clinics spawned throughout the island; sometimes even in the most unlikely places! In the past, a practitioner would nurture a practice for years before nurturing another. These days, they toss a bunch of seeds and hope they’ll grow by virtue of branding. If you plan to set up 100 clinics, of course you will need at least 100 dentists. If you don’t have 100 dentists, then of course there is a “shortage”. But is your aging population enough to sustain the 100 dental clinics that have been set up at today’s prohibitive costs?

Dentists without such lofty ambitions don’t care if foreigners want to flush their money down the drain. But this denied or ignored oversupply of dentists and dental services in the private sector is super-saturating the market, promoting vicious competition, desperate measures and even unhealthy practices like backstabbing and badmouthing within the profession.

There is another qualitative issue that increasing the number of dentists does not address. It is an irony that when the population was aging far slower decades ago, dentists then were more acquainted with extractions, dentures and other unsophisticated, quick fix treatment that the elderly would normally ask for. Today’s dentists are more into implants and orthodontics. A recent seminar on geriatric dentistry saw a pathetic number of participants. What do you expect? Clinic operating costs are high. A dental education is very expensive, so naturally the young and virile dentists go where the money is. So is there a mismatch between what dentists want to do and what the aging population needs? If there is, then training more dentists, setting up more clinics and importing more foreign talent simply won’t work. Does the argument for more dentists based on an aging population hold any water?

It really saddens people in the know to see the stark realities on the ground while policy makers continue to inflate the bubble based on some imaginary problem treated with the wrong medicine. Of course, all this cannot last forever. The sooner those foreign investors and academic experts can come to their senses, the better. I wish I could get out of the way when the bubble bursts.

Many people are under the impression that dentists earn a lot of money. Hence, whenever there’s any news that dentists may suffer a huge loss of income from some disruptive technology, the public would appear to have reason to celebrate. Here’s one. Researchers at King’s College London found that the drug Tideglusib stimulates the stem cells contained in the pulp of teeth so that they generate new dentine – the mineralised material under the enamel. This new drug has been touted as something that will end restorative dentistry with filling materials.

Not surprisingly, the article went viral, but exactly what was it trying to say when it suggested that “Teeth already have the capability of regenerating dentine if the pulp inside the tooth becomes exposed through a trauma or infection”

Any person with a basic knowledge of tooth development would know that this statement is untrue. First of all, the pulp forms secondary dentine all the time. However, the pulp does not push outwards as it forms the secondary dentine. It pushes inwards, painting itself into a corner if you will. That’s why young teeth have comparatively large pulp chambers while older teeth have smaller ones. As the tooth grows older, the pulp shrinks and becomes smaller and smaller. Meanwhile, the external surface of the tooth continues to wear out. No actual “regeneration” occurs.

A young, healthy tooth has a relatively large pulp chamber. The growth of new dentine forces the pulp inwards. There can be no change in the external dimensions of the tooth.

A young, healthy tooth has a relatively large pulp chamber.

The process of secondary dentine formation can be sped up when the pulp senses decay and mild irritation coming from the surface of the tooth. This is a protective measure and not a very ingenious one if you ask me. However, if the highly sensitive and fragile pulp tissue becomes exposed through trauma or infection, it almost always becomes non-vital. It is simply untrue that exposed, infected or injured pulp can still generate dentine as suggested by the article. Once the pulp has been exposed due to caries or trauma, root canal treatment is seldom avoidable.

Unless the evolution of human cell biology has taken a drastic turn, I don’t see how inserting a collagen sponge impregnated with some miracle drug can cause the pulp to build dentine outwards and fill up the cavity.